| BackgroundWith the development of social economy,factors such as the aging of the population and the increasing prevalence of chronic diseases have led to the increasing risk of residents seeking medical treatment and the increasing demand for health services,resulting in a relatively serious social and economic burden.In 2009,the new medical reform proposed the connotation of"hierarchical diagnosis and treatment" and established the strategic goal of "ensuring the basic level and strengthening the grassroots level".In 2015,hierarchical diagnosis and treatment was formally put forward as a system.It is further defined to strengthen the capacity building of community-level medical services,establish division of labor and cooperation among medical institutions,improve the efficiency of medical resource utilization,and make the order of medical treatment more reasonable and standardized.As a populous province,how to guide residents to seek medical treatment at the grassroots level,how to maximize the use of limited medical and health resources,to provide high quality and efficient medical and health services for the residents of Shandong Province is a major social problem facing at present.Driven by the new medical reform,the pilot work of graded diagnosis and treatment was officially launched in Shandong Province.This study uses a combination of data from the National Health Service Survey Shandong and self-designed onsite research and interviews to understand the current situation of hierarchical diagnosis and treatment in Shandong Province,analyze residents’ choice of medical treatment and the reasons for their choice and the factors influencing primary care,explore the influencing factors of residents’ willingness and behaviors to seek primary care.We propose policy recommendations to promote the implementation of the policy of graded diagnosis and treatment.Research objectiveThe overall objective of this paper is to promote the effect in the implementation of primary diagnosis of residents in Shandong Province as a starting point,from the aspects of optimizing the implementation effect of the hierarchical diagnosis strategy,understanding the situation of residents’ choice of primary diagnosis,exploring the factors influencing the willingness of residents to choose primary diagnosis,etc.,in order to provide empirical data and reference basis for the relevant health administration departments.Specific objectives include:1.From the perspective of health policy,summarize the implementation status and main problems of related strategies of hierarchical diagnosis and treatment in Shandong Province,so as to provide theoretical basis for improving the attraction ability of medical treatment selection of primary medical service system.2.From the perspective of demand-side medical treatment behavior,the situation of illness,health service utilization and medical treatment choice of residents in Shandong Province under the background of hierarchical diagnosis and treatment was analyzed,mainly from the two aspects of residents’ choice of first consultation institutions and residents’ referral to medical treatment.3.From the perspective of causes and trends,explore the influencing factors of residents’choice of primary diagnosis in Shandong Province under the background of hierarchical diagnosis and treatment,as well as the changes of residents’ choice of medical treatment in Shandong Province.4.From the perspective of demand-side influence factors,study the influence factors of residents’ willingness and behavior of primary care in Shandong Province under the background of graded diagnosis and treatment.5.To analyze the problems and shortcomings of the primary diagnosis in the implementation of hierarchical diagnosis and treatment in Shandong Province,and to provide relevant policy suggestions for further deepening the implementation of hierarchical diagnosis and treatment system and establishing a good medical order.Method1.Sources:The qualitative data included literature and interview data.The literature data were obtained from various academic databases in Chinese and English,and the relevant health policy documents were obtained from the official websites of governments or departments at all levels;the interview data were obtained from self-designed and distributed semi-structured interviews on patients’ willingness and behavior of primary care in the context of hierarchical diagnosis and treatment.The quantitative data include official policy data,official survey data and self-designed research data.Statistical data involved in the study of primary care service capacity and implementation of related health strategies were obtained from the 2014-2022 Shandong Health and Family Planning Statistical Yearbook,Shandong Health and Health Statistical Yearbook,Shandong Health and Health Work Statistical Bulletin,and National Health and Health Statistical Yearbook;on-site survey data on residents’ choice of medical institutions for consultation and primary care service capacity were obtained from the fifth(2013)and the sixth(2018)National Health Service Survey Shandong Province sample;the statistical data for the study design of residents’ willingness and behavior of primary care were obtained from self-designed and implemented interviews and structured questionnaires.2.Analytical methods:First,based on Anderson Health Service Utilization Model to analyze residents’ choice of medical treatment in Shandong Province,and Biprobit model was used to estimate the influencing factors of health records and family doctors on patients’primary care,and Heckprobit model was used to estimate the influencing factors of primary care,which effectively circumvented the selection bias of the sample.Second,structural equation model was constructed based on the theory of planned behavior.The greatest advantage of structural equation is to simultaneously handle latent variables that cannot be directly and accurately observed,as well as explicit indicators that indirectly measure latent variables.To explore the important factors that can influence patients’ willingness and behavior in the process of primary care,the structural equation model was constructed based on five dimensions:patients’ subjective norms,behavioral attitudes,perceived behavioral control,patients’ willingness to seek primary care,and patients’ first visit behavior,and analyze the influencing factors and correlation strength between willingness to first visit and behavior.Results1.Operation status of the hierarchical medical systemShandong Province actively promotes the construction of the hierarchical medical system,solidly promotes the construction of medical consortia and medical communities,enhances the medical service capacity of counties,and explores the formation of effective models such as the "remote medical cooperation network" model in Jining City,the "county medical community+medical insurance per head payment" model in Qingdao City,the "medical student group" model in Jinan City,and the "integrated chronic disease management" model in Wudi County Binzhou City.However,the hierarchical allocation of health resources in medical institutions in the form of an "inverted pyramid" is still evident,and tertiary hospitals still bear a heavy burden of diagnosis and treatment services and inpatient services.The role of primary health institutions in primary diagnosis has not been fully played.2.Current situation of residents’ choice of medical treatment(1)Residents’ illness and consultation:85%of the residents will choose to seek medical treatment after falling ill,and the untreated rate is higher among urban residents than rural residents;the proportion of residents with medical needs,better health awareness,contracted and aware of family doctors and established health records seeking medical treatment is higher.(2)Analysis of outpatient and inpatient referrals:the outpatient referral rate is low(0.6%),and the vast majority of patients are direct patients,even in higher-level hospitals,the proportion of patients referred is very low;compared with outpatients,inpatients are relatively more serious and have a clearer need for medical services.so they are more likely to be referred(3.4%).(3)Choice of first medical institution:the highest proportion of patients in rural areas(48.14%)visited village health offices,while patients in urban areas tended to visit county and city hospitals,prefectural and provincial hospitals.with a higher proportion than in rural areas;younger patients tended to choose clinics as their first medical institution compared to older patients;poor families’ first choice for medical treatment was mainly primary medical and health institutions;retired people went to Patients with urban and rural residents’ medical insurance tend to choose clinics(village health offices)for their first consultation.while urban employees’ medical insurance patients visit county-level medical institutions for the first time;the proportion of residents who have signed up for family doctors prefer primary medical institutions than those who have not signed up for family doctors;those who are less than 1 km away from the nearest medical institution have a higher proportion of first consultation choices in each medical institution.The proportion of residents who preferred rural medical institutions was about 77.57%.3.Influencing factors of resident primary diagnosis(1)Analysis of factors influencing the first visit:among the personal predisposition factors.female(β=0.109,P=0.047),aging(β=0.238,P<0.001),rural(β=-0.287,P<0.001),and low educational level(vs secondary education:β=-0.113,P=0.027;vs higher Education:β=-0.412,P<0.001)patients were more inclined to choose primary health care institutions for their first visit;among the demographic enabling factors,patients,who owning higher income(β=-0.179,P=0.002)and retiring(β=-0.273,P=0.002),were less likely to choose primary care.At the level of population health needs,patients with chronic diseases(vs 1 type:β=0.272,P<0.001;vs 2 and more types:β=0.363,P<0.001 were more likely to choose primary care.(2)Analysis of reasons for choosing the first medical institution:proximity to the medical institution or convenience of medical treatment are the primary considerations of residents when choosing the medical institution.The second is reasonable fees,fixed units,good service attitude,reliable doctors and so on.The proportion of urban residents who pay attention to medical technology is the highest.For those who are less than 1 km away from the nearest medical institution,proximity(convenience)(79.29%)or designated unit(81.05%)is the primary consideration when choosing a medical institution.4.Changes in residents’ choice behavior and satisfaction with first visitBehavioral changes in residents’ choice of first consultation:Generally speaking,compared with 2013(80.58%),the grassroots consultation rate of residents in Shandong Province did not change significantly(χ2=0.052,P=0.891)in 2018(80.84%).Further heterogeneity analysis on the choice of primary care for residents with different characteristics showed that compared with 2013,among the survey subjects in 2018,patients over 60 years old(χ2=8.138,P=0.004),with some problems in self-care(χ2=8.026,P=0.005)/unable to take care of themselves(χ2=1.041,P=0.038),hypertensive patients(χ2=4.094,P=0.043)and diabetic patients(χ2=6.547,P=0.011)tended to go to primary care.5.Mechanisms influencing residents’ willingness to seek primary care and behavior(1)In terms of patients’ willingness to seek primary care’ subjective norms had a significant positive effect on willingness to seek primary care(β=0.515,P<0.001),behavioral attitudes had a significant positive effect on willingness to seek primary care(β=0.254,P<0.001),and the degree of perceived behavioral control had a significant positive effect on willingness to seek primary care(β=0.258,P<0.001).The influence mechanisms of patients’willingness to seek primary care were subjective norms,degree of perceived behavioral control,and behavioral attitudes,in descending order of strength.(2)In terms of patients’primary care behavior,there was a significant positive effect of primary care intention on primary care behavior(β=0.209,P<0.001),and the effect of perceived behavioral control on primary care behavior was not significant(β=-0.026,P=0.506).Conclusions and policy recommendations1.Main conclusions(1)The guiding effect of strategies related to hierarchical diagnosis and treatment on grassroots medical treatment of residents has not been fully played.(2)The service capacity of primary medical institutions needs to be further developed and improved,and the "inverted triangle" structure of resource allocation formed by health manpower in medical and health institutions on the supply side has not been effectively reversed,which does not meet the needs of residents in the "normal triangle" of medical treatment in hierarchical diagnosis and treatment.(3)The primary medical institutions were the main choice of residents,but there were obvious individual heterogeneity and regional differences.(4)Residents with chronic disease,good medical experience,holding and knowing health records have higher intention of first diagnosis at grassroots level.(5)Patients’ subjective norms,behavioral attitudes,and perceived behavioral control can all influence patients’ primary care hospitals,and patients’ primary care intentions can influence patients’ primary care behaviors,but the latter are not entirely determined by the former.2.Policy Recommendations(1)Improve various systems and policies to help the formation of hierarchical diagnosis and treatment pattern.(2)Optimize the allocation of medical resources and improve the ability to provide grassroots medical services.(3)Define the functional positioning of diagnosis and treatment services in hospitals at all levels,simplify medical referral procedures and improve referral efficiency.(4)Publicize the policy of graded diagnosis and treatment through multiple channels to guide residents to form the awareness of graded diagnosis and treatment.(5)Improve the quality of diagnosis and treatment services in primary medical institutions,optimize residents’ medical experience and improve their satisfaction.(6)Change residents’ concept of medical treatment and cultivate residents’ habit of medical treatment at grassroots level. |
